Trauma Verification Q&A Web Conference November 16, 2017 COTVRC@facs.org
Your Trauma Quality Programs Staff Tammy Morgan Manager Trauma Center Programs Molly Lozada Program Manager Trauma Verification Rachel Tanchez Site Visit Coordinator Trauma Verification
Continuing Education (CE) To qualify for CE, you must attend at least 50 minutes of educational content An email will be sent to all attendees who qualify for CE within 24 hours of the webinar ending, with instructions on how to claim CE If you have any questions please email COTVRC@facs.org
What is the goal for this Webinar? Interpret the standards outlined in the Resources for Optimal Care of the Injured Patient manual to ensure that hospitals have an understanding of the criteria to provide quality care to the injured patient. Understand the processes and standards involved in an ACS Trauma Verification Site Visit and how following these will positively impact the quality of care of the injured patient at your center.
Let s get started!
Orange Resources Book Available as hard copy or PDF version, it is recommended that you have it available as reference during the CD-Related Questions section of this webinar. Must use the most current Clarification Document and the Verification Change Log in conjunction with the manual. www.facs.org/qualityprograms/trauma/vrc/resources
Clarification & Verification Document Updates The updates for the Verification Change Log and Clarification Document through June have been completed. These documents may be accessed through the VRC webpage at: www.facs.org/quality-programs/trauma/vrc/resources. Going forward, changes to the criteria will be published in the Verification Change Log, and any clarifications to criteria will be published in the Clarification Document.
Clarification Document Updates sent to participants monthly
Verification Change Log Updates sent to participants monthly
Recording of Webinars The webinars are recorded during the session and will be posted within one week on the ACS YouTube channel. You may also access them via the VRC resources webpage at: https://www.facs.org/quality-programs/trauma/vrc/resources.
Disclaimer All questions are pulled directly from the question submissions. There have been no edits made to the contents. If your question is not answered today, the question may require more information, and will receive a response from ACS staff within one week after the webinar.
Announcements
Next Verification Q&A Webinar Deadline to submit questions: Friday, December 1, 2017 Webinar date: Friday, December 15, 2017 Webinar time: 1:00pm-2:00pm CST
Resources Revision Process The Stakeholder Public-Comment website: https://www.facs.org/quality-programs/trauma/vrc/public-comment We strongly encourage everyone to review and comment on the standards. Your input will help guide the revision process to add, modify, or retire requirements. Upcoming Chapters Call for Under Completed Approved Data Revision Chapter 6 General Surgery X X Chapter 7 Emergency Medicine Chapter 8 Neurosurgery Chapter 9 Orthopaedic Surgery Chapter 10 Pediatric Surgery Chapter 15 Trauma Registry Chapter 19 Research X X X X X X
Resources for TPMs and TMDs Frequently Asked Questions (FAQs) The list will expand over time. https://www.facs.org/quality-programs/trauma/vrc/faq Becoming a Verified Trauma Center: First Steps Designed to guide the Trauma Program Manager or Medical Director in the First Steps in the Consultation and Verification Process. https://www.facs.org/quality-programs/trauma/vrc/resources
Scheduling Reminders
Site Visit Application The application must be received at least 13-14 months in advance of the requested time frame or current expiration date. This will hold your spot and, in addition, provide centers plenty of time to prepare and complete the online PRQ. The lead time is required due to the multitude of applications received. Visits for 2017 and through November 2018 are closed to scheduling: https://www.facs.org/quality-programs/trauma/vrc/sitepacket
Additional Information to be submitted with Site Visit Application Orthopaedic Traumatologist Leader (OTL) form Required for: Level I Trauma Centers Level I Pediatric Trauma Centers Level I Adult and Level II Pediatric Trauma Centers Combined centers (Leve I adult/level I pediatric) that have separate visits scheduled, but share the same OTL, the form must be completed entirely for the 1 st visit and on the 2 nd visit, only complete questions 1-3. The form is located at: https://www.facs.org/qualityprograms/trauma/vrc/site-packet
Alternate Pathway Criteria (APC) Request For centers that have a non U.S. or Canadian board certified/eligible physician or surgeon, who has trained overseas, must note the applicant s name and specialty on the application. Forward a copy of the applicant s curriculum vitae (CV) On-site evaluation by a member of the same specialty; assess the 8 criteria (ATLS, CME, meeting attendance, etc), along with review of clinical care Those previously approved by way of the APC are not required to have a review by the specialist at the time of the visit. However, they are required to meet the APC. The APC is not applicable to U.S. or Canadian residency trained physicians or surgeons. https://www.facs.org/quality-programs/trauma/vrc/site-packet
Prereview Questionnaire (PRQ) Online Access Once your application has been received, the VRC office will provide you with an email receipt of confirmation. Logins to the online PRQ will be provided within the confirmation of receipt email The online PRQ can be accessed at: http://web2.facs.org/traumasurvey5/ A copy of the PRQ in Word can be downloaded from: www.facs.org/quality-programs/trauma/vrc/resources
Site Visit Application Payment Do not submit payment with the application Your center will be billed annually for the Trauma Quality Program fee This annual fee will not include any additional visitrelated fees, such as additional reviewers The fee structure is located at: https://www.facs.org/quality-programs/trauma/vrc/fees
Scheduling Site Visits Visits are typically scheduled within 90 days prior to the requested timeframe. Ideally, all visits will occur during the center s preferred timeframe. When a lead reviewer is available for your site visit, VRC staff will contact your TPM to confirm the dates prior to finalizing the visit.
Site Visit Preparation with Reviewers The ACS Travel Agent will arrange the site reviewers flights. Reviewers make travel plans approximately 20 to 30 days prior to the site visit. The hospital will arrange and pay for the site reviewers hotel accommodations, as well as their ground transportation. The reviewer s contact information will be provided in a confirmation email once the full team has been secured, approximately 90 days before the visit. Please contact the reviewers directly within 30 days of the site visit for their flight Itinerary and any logistical information.
General Questions
PRQ Medical Records Data reporting period. For PRQ deadline, charts are not all complete. Do we just submit what we have an update upon sit visit? (Level 1) The data should reflect the reporting period that will be used to complete the PRQ. Ideally, the medical charts should follow suit and be available onsite for the reviewers. If there are cases that are not yet closed, you should not include those at the time of the visit.
PRQ Lifetime Board Certification One of our orthopedic surgeons was grandfathered in for Board Certification, documented as Lifetime duration. This means he does not have an expiration date. How should that be documented on the PRQ and to reviewers? (Level 2) Correct, there is no expiration date for Lifetime board certification. You would list Lifetime in the column that is asking for the year. For the site reviewers, have a copy of the orthopaedic surgeon s certificate at the time of the site visit.
PRQ for Pediatric Trauma Centers Can you please tell us why ACS cannot have a separate PRQ for pediatrics? It is so confusing to fill out the same PRQ for both. (Level 1) We are working on developing a separate pediatric PRQ. There are some differences if you are a Level I adult and a Level I pediatric trauma center. As you may be aware, the PRQs are programmed to display specific questions that are relevant to your trauma level and patient type. For those centers that are seeking pediatric verification, although you will not see the word pediatric inserted in many of the questions, all questions are to be answered using pediatric data.
Verification Recommendations Is there a maximum number of not met recommendations that will cause you to fail or result in a clinical deficiency? (Level 1) There is not a maximum number of recommendations that will result in a deficiency. A center may have various recommendations which are based on opportunities for improvement cited during a site visit. Centers should make an effort to address these opportunities and recommendations at the time of a site visit. For an onsite Focused review, an action plan is required, and within the action plan, the opportunities for improvement/recommendations should be addressed we are not asking to have them implemented; however, the center should demonstrate an effort to address them.
Verification Status Change If a verified center wants to change status to a lower level, what is the process at that time of re-verification? (Level 1) If a center is currently verified as a Level I, and has determined that it will not meet the Level I standards at the time of renewal, the facility may apply to be verified as a Level II or III at the time of application. If a center is currently verified as a Level II or III and is seeking to be verified as Level I or II at the time of renewal, the facility may apply as such at the time of application. If the center is unable to meet the standards as a Level I or II, the center may submit a written request following the site visit to be verified at its current level. In both scenarios, it is expected that the center meets all requirements for the level at which it will ultimately be verified.
OTL Form Does the same orthopedic liaison (fellowship prior to 2013) have to be vetted for each survey period, or is once enough? (Level 1) To clarify, the OTL and orthopaedic liaison may be different people. If the OTL has already been approved and has not changed at your center, we do not need to vet them again. However, please provide his/her name and note that they were previously approved. We will update the OTL form to include new or previously approved as a category.
Transfers-In We had a question regarding patient received from urgent care clinics. Are these patients considered as trauma transfers? (Level 1) Yes, they are considered transfers-in to your facility. The same would be true for those trauma centers that have a satellite (free standing) emergency department.
Performance Improvement Documentation The TMD sometimes conducts education and counseling for minor care issue undergoing secondary level review by sending an email to the involved provider. The fact an email was sent by the TMD is noted in the PI for that particular patient and issue. Is this sufficient documentation? (Level 1) Yes, an email is acceptable. However, I would also include a copy of the email in the PI chart, and any verbal discussions should be noted.
Activation Criteria If a pediatric patient presents through triage with a head injury, aox3, [is stable] and does [NOT] meet activation criteria but is found later to have an Epidural bleed, is it recommended to activate at that time, OR, can Neurosurgery solely be notified and then be held [to the 30 min response time]? (Level 1) If the assessment is done by the APP and the injury meets activation criteria, the activation should be called. It may be best to call the activation since the trauma attending is required to respond within 15 minutes and there may be additional injuries that the neurosurgeon may not identify. However, if the assessment is done by the trauma attending, then they may notify the neurosurgeon since the patient has been assessed. The over/under triage rate may be impacted if the patient met activation criteria and an activation was not called.
Documentation of GCS Do physicians and nurses both need to document a GCS scale on the patient record? Is a reading from one specialty acceptable? (Level 3) Yes, both the nurse and physician would need to document the GCS on the patient records. Refer to the NTDS for the Data Source Hierarchy Guide.
Death Cases Clarification of Review Agenda, Adult Center treating peds too need to pull 30 deaths with a mixture of both or 20 extra peds? (Level 2) With regard to the trauma deaths, based on the center s Mortality review: Adult trauma center treating adult & pediatric Pull a minimum of 30 medical records with a combination of adult & pediatric, if available Adult trauma center only Pull a minimum of 30 medical records, if available Pediatric trauma center only Pull a minimum of 20 medical records, if available Combined [verification] adults & pediatric center Pull 30 adult & 20 pediatric medical records, if available Note: if unable to pull the minimum requested, pull what is available at the time of the visit.
Ground Level Falls What does the committee want to see for data collection on falls? (Level 1) Same/ground level falls/isolated hip fractures - If these patients meet the NTDS inclusion criteria, they should be captured in your trauma registry, and if the center includes them in the volume admission numbers (on the PRQ), then you must follow all the rules of any other trauma admission such as, nonsurgical admissions, PI, etc. (refer to CD 5-18). This may differ from your state inclusion criteria. Therefore, you may have to capture 2 sets of data points.
Bypass (Diversion) Are transfer denials considered bypass and if so, should we be logging time etc. (Level 1) Based on this question, transfer denials from another facility would not be considered a bypass. However, I would be more concerned as to why a Level I would not accept a transfer and recommend that these instances are documented and reviewed through the PIPS process.
Geriatric Patients Does ACS expect a level I to have a geriatric program or can they speak to the pathway that is used to manage this population? (Level 1) Trauma centers are not required to have a geriatric program. It would be ideal to have one if the trauma center sees a high volume of these patients, but it is not required. The expectation is for the program to have a process or guidelines in place for these types of patients. Have this readily available at the time of the visit.
CD-Related Questions
Neurosurgery Response (CD 8-2) If our Neuro Critical Care intensivist responds to the ED within 30 minutes of notification, is this an acceptable alternative to the Neurosurgeon response time as long as they are documenting that they are communicating with NS regarding the surgical options and plan of care for the trauma patient (ie as an alternate to the NS resident or APP mentioned in the previous clarification)? (Level 2) Yes, that is an acceptable practice. Typically, we refer to residents and APPs as the responder; however, if the neuro intensivists have been approved to respond to the critical management of neurotrauma patients, that is acceptable.
Neurosurgeon Credentialing (CD 8-5) Please expand upon the required credentialing for trauma surgeons to provide initial evaluation and stabilization of the neurotrauma patient. How is this different than the credentials/privileges already granted to a TS? Are there specific elements that must be included? (Level 3) The credentialing process will be established by your center. If the trauma surgeon is trained to provide initial evaluation and can perform either a medical intervention or surgical management such as, do a burr hole and transfer the patient, that would be acceptable.
Pediatric Trauma Manager (CDs 10-3/10-5) Level I and II pediatric trauma centers must have a dedicated pediatric trauma program manager (CD 10 3). In a Level I pediatric trauma center, the pediatric trauma program manager must be a full-time position dedicated to the pediatric trauma service (CD 10 5). Dedicated is defined as overseeing and working for the trauma program. This does not include serving as the program manager for the Children s Surgery Verification program. Note: In a Level II pediatric trauma center, the pediatric trauma program manager should be dedicated to the pediatric trauma service, but need not be full-time, and may also serve as the prevention coordinator or registrar.
Radiologist Response (CD 11-33) CD11-33 Radiologist Response for Intervention: Is this from time of call to the start of the procedure or patient in room ready? (Level 1) The response is tracked from time of call for the service to bedside, not incision/procedure time.
ICU Coverage (CD 11-56) Would a critical care trained Nurse Practitioner qualify as a credentialed provider for coverage of the ICU in a level III center? (Level 3) Based on Chapter 11 on page 81 Table 1, coverage must be provided by a physician, which may be the ED physician or an intensivist.
Specialty Services: Ophthalmology (CD 11-71) In a Level II center do we need to be able to provide 24/7 ophthalmology surgery as well as plastic surgery? (Level 2) For Level I and II trauma centers, OMFS and plastic surgery services are required. The Orange book is silent on the call schedule piece, but the expectation is that if the trauma surgeon requests a consult from OMFS or plastic surgery, there must be a process whereby who is on call for OMFS/plastic is documented. In addition, these specialists are not required to be in house 24/7; however, based on institutional guidelines, the specialists must be available in-person at bedside at a predetermined time when the consult is requested.
Fresh Frozen Plasma (CD 11-83) For blood bank compliance; Does FFP need to be thawed within 15min. or available to be thawed within 15min? (Level 3) It is not expected to have the FFP thawed within the 15 minutes. We realize it will take much longer for that to occur. Therefore, the expectation is for the FFP to be available to be thawed in 15 minutes.
ATLS (CD 11-86) Interns work under the supervision of Attending. Do they need ATLS if they are present at the initial resuscitation? (Level 1) If the interns are members of the trauma team activations (high or limited), and will participate in the evaluation and resuscitation of the trauma patient, they are required to be current in ATLS (CD 11-86). If interns or PAs see "trauma" patients during the consultation phase, they are not required to be current in ATLS.
TQIP Enrollment (CD 15-5) For the consultation visit, will we be required to have 1 yrs worth of data for the reviewers available in TQIP? (Level 1) No. For new trauma centers seeking a consultation visit, if the center is fully enrolled (signed contract & payment) in the program, but has not yet submitted data or received a benchmark report, the center will not be cited a deficiency. For new trauma centers seeking a consultation visit and it has not applied for TQIP, the deficiency will be cited. At the time of verification, the center will be expected to be fully enrolled in TQIP.
Registry Cases (CD 15-6) What is the latest 80% criteria for the Registry: Cases entered or Cases Closed? (Level 1) The percentage of completed registry records entered within 2 months of discharge (the threshold is 80 percent). Centers are encouraged to stay concurrent. There are some centers that set the bar high such as, cases over the weekend are entered into the registry within a week. Again, this is set by the center and is dependent on the number of FTEs available to provide this type of support.
Registrar (CD 15-9) Can you please provide a staffing ratio breakdown? The orange book is very basic stating 1 FTE per 500-750 cases. (Level 3) Is there any plan to change the requirements for trauma registry staff from the 500-750 patients? (Level 3) The current standard is one full time employee for every 500-750 admitted trauma patient into the registry based on the time needed to code and capture NTDB/TQIP data points. Registrars have other duties such as, generate reports, perform data analysis, act as research assistance, and meet various submission requirements that will decrease the time dedicated to the collection of patient data. More detailed information can be found in Chapter 15 page 112. There are discussions and plans to revise this standard.
Universal Alcohol Screening (CD 18-3) Standard for ETOH screening states all. Is there an acceptable percentage other than all? Some injuries/tbi prevent screening? (Level 1) This was changed from All patients to all patients that meet the NTDS Trauma Inclusion Criteria with a hospital stay of > 24 hours for at least 80% of the patients. This does include all injuries, ortho and neuro.
Research (CD 19-1/19-4) Clarification: Articles that have been approved/accepted for publication are acceptable to use to meet the research requirement. Have documentation that states it has been accepted available at the time of the site visit. All research must result from work done at your trauma center. Work done in collaboration with other trauma centers and participation in multicenter investigations may be included. If the center has a new provider in which he/she did research at another facility, that research cannot be used at your center or count toward the requirement.
CME: Specialty Specific Does trauma related CME need to be specialty specific? (Level 2) The CMEs should be applicable to the surgeon/physicians area of specialty; however, not all (48 hours) are required to be specialty specific. The CME must be relevant to the management and care of the injured patient.
CME: Prorated Clarify Prorated CME? CME calculated from 2015 to 2017, how many CME a physician who joined in April 2016 will need: 32 or 24? (Level 1) CMEs will be prorated for new centers seeking verification as 16 hours annually for all specialties. For those centers that have new hires/residents during the 3 year verification cycle, the CMEs are prorated beginning from the time of hire. When completing the PRQ, question asking if all are in compliance for CME, answer as yes. In the appendices, type an symbol (*) next to the new hires name and add a note in a blank field at the bottom of the page as: *prorated new hire.
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